To our knowledge, there has been no formal statistical evaluation of the trends of nasal tip management in rhinoplasty. Our first objective was to evaluate the changing trends in septorhinoplasty techniques for nasal tip contouring, within a single-surgeon, private facial plastic surgery practice. Our second goal was to determine if this change in techniques has led to improvement in outcomes.

Methods

We performed a retrospective medical chart review consisting of 2 groups of 50 consecutive patients who had undergone rhinoplasty. The 2 groups spanned a 10-year period, one from 1999 and the other from 2008. The study took place at a private facial plastic surgery practice with a focus on rhinoplasty, recognized as a center for revision rhinoplasty referral, in a major metropolitan area. Data collection included patient demographics and types of tip-plasty maneuvers performed. These techniques were categorized as either (1) reductive maneuvers or (2) stabilizing and strengthening maneuvers. The usage of the maneuvers was compared between the 2 patient groups using the χ2 test of association and Fisher exact test (where warranted by small sample size). The outcome measure was revision rate used as a surrogate measure for surgical success.

Results

There was no statistical difference between the groups in terms of age (P = .69), sex (P > .99), or percentage of primary vs revision operations (P = .51). The mean age of the patients was 32.5 years (range, 15-70 years) in 1999, and 31.5 years (range, 10-60 years) in 2008.

The nasal tip contouring maneuvers evaluated in this study were classified as either reductive or stabilizing and strengthening and are summarized in the Table. Of the tip-plasty maneuvers deemed to be reductive, there was a statistically significant decrease in medial crural excision (P = .001), lobule scoring (P = .004), lateral crural release (P = .01), and cephalic trim (P = .03), with no change in the remaining techniques. Of the tip-plasty maneuvers deemed to be stabilizing and strengthening, a statistically significant increase was noted in the usage of lower lateral crural strut grafts (P < .001), alar margin grafts (P < .001), lateral crural overlay (P < .001), columellar plumping grafts (P = .005), and supratip grafts (P = .003), with no change seen in the use of the remaining stabilizing techniques. There were no reductive techniques that were increasingly used, and no stabilizing techniques with diminished use over the 10-year time period. This substantial shift in tip-plasty techniques is demonstrated in the Figure. Although there was a decrease in the rate of revision rhinoplasty, this decrease was not statistically significant (3 vs 1; P = .62).

Comment

Reductive Maneuvers

The reductive procedures can be divided into 2 subcategories: excisional techniques and weakening techniques. The excisional techniques can involve cartilage (cephalic trim, medial crural excision, lateral crural excision, and caudal septal shave) or soft tissue (alar base reduction, alar margin skin excision, and membranous septal excision).1 The cartilage excisional techniques are destabilizing to the underlying skeletal support, whereas the soft-tissue excisions tend only to contour or sculpt the surface. The results demonstrate that most of the cartilage excisional techniques decreased over the evaluation period, whereas there was no change in the soft-tissue excisional techniques.

The weakening techniques can involve release (lateral crural release and medial crural release) or scoring (lobule scoring, medial crural scoring, and lateral crural scoring). Both types of weakening procedures were either not performed routinely in the early cohort (lateral crural scoring, medial crural scoring, medial crural release) or had a statistically significant decrease over the evaluation period (lobule scoring and lateral crural release).

Stabilizing and Strengthening Maneuvers

The subset of maneuvers classified as stabilizing and strengthening share the characteristic of not reducing or excising tissue. They can be categorized as cartilage overlay techniques (lateral crural overlay, intermediate crural overlay, and medial crural overlay), suture techniques (interdomal and intradomal), structural grafting techniques (lower lateral crural strut graft, columellar strut graft, lower lateral crural batten graft, and caudal septal extension graft), contour grafting techniques (supratip graft, tip graft, and infratip graft), and combination grafting techniques (alar margin graft, columellar plumping graft, and sill graft). Although the cartilage overlay techniques involve a division perpendicular to the long axis of the alar cartilage, the 2 flaps are overlapped, creating a double layer that is stabilized with sutures.2,3 This resultant dual layer is stronger than the initial single layer and resists buckling.4 The suture techniques not only avoid cartilage excision but also augment stiffness of the cartilage. The structural grafting techniques increase the ability of the nasal tip skeleton to resist the contractile forces of healing and the tendency of the nose to weaken with age. The remaining grafts share the quality of adding bulk and varying degrees of structural stability. The data analysis demonstrates a statistically significant increase in some of the maneuvers, without any decrease in any of the maneuvers in this category.

Evolution in Practice

Our objective was to determine if the changing philosophy of rhinoplasty—from reductive to stabilizing and strengthening techniques—led to improved outcomes by using revision rates as a surrogate marker of success. The analysis demonstrates a shift in the techniques within this practice that parallels the shift in the rhinoplasty literature. However, the decrease in revision rates between the 2 cohorts in this study was not significant.

Certainly, it is difficult to draw clear conclusions from this observation. First, this is an evaluation of a single-surgeon practice and therefore is subject to the associated biases. Second, the senior author (P.A.A.), who was the primary surgeon for all of the rhinoplasties, was already using structural strengthening techniques (eg, columellar strut) in the early cohort; therefore, there is cross-contamination between the 2 groups.

As rhinoplasty surgeons progress through their career, they are often presented with more difficult cases and an increasing proportion of revision cases. It is reasonable to assume that patient expectations are higher for an experienced surgeon as opposed to a more novice one. This combination of increased case complexity and increasingly discriminating patients can potentially counter the improving skill of an experienced surgeon, leading to a fairly stable revision rate of 5% to 15%.5

In the case of an expert surgeon who would tend to accept more challenging cases as his career progressed, and against the backdrop of a clientele that is becoming increasingly demanding as access to information educates their expectations, one might expect that revision rates should not decrease, and might even increase, for the senior surgeon in his later cohort. But this was not the case. Instead, the escalating complexity of his caseload was paralleled by his increasing usage of stabilizing and strengthening techniques, and his revision rates decreased; perhaps this highlights the effectiveness of these maneuvers in controlling revision rates.

In conclusion, we report the first study, to our knowledge, to statistically evaluate the anecdotal notion of a shift in the practice of rhinoplasty. Congruous with the overall evolution of the philosophy of rhinoplasty apparent in the literature, the results of this study demonstrate a decrease in reductive techniques with a concurrent increase in stabilizing and strengthening techniques. This trend may contribute to reduced revision rates, particularly in the setting of complex, second-attempt rhinoplasties.